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Environmental Perspectives #1

Community Solutions to the Challenges of Childhood Obesity November 4, 2005 “ It’s easier to build a child than fix an adult .” Eduardo J. Sanchez, M.D., MPH Commissioner, Texas Department of State Health Services. Environmental Perspectives #1.

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Environmental Perspectives #1

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  1. Community Solutions to the Challenges of Childhood Obesity November 4, 2005“It’s easier to build a child than fix an adult.”Eduardo J. Sanchez, M.D., MPHCommissioner, Texas Department of State Health Services

  2. Environmental Perspectives #1 • An aging population with increasing medical care costs • An increasing Hispanic population • An epidemic of obesity • An explosion of type 2 diabetes • A significant # of Texans with mental illness and/or substance abuse conditions

  3. Environmental Perspectives #2 • A shortage of healthcare providers • Wide, & in some cases, growing health disparities • The challenge of improving health literacy • The highest % of residents without health insurance • Compelling reminders Texas must be prepared for natural and man-made disasters

  4. I. The “Whole Person” Context Sound Mind, Sound Body

  5. Three Guiding Principles Sound Mind, Sound Body Prevention first, treatment if necessary Partnership

  6. Adverse Childhood Experiences (ACE) Study • In the mid-1980s Kaiser Permanente conducted an obesity program • In trying to understand the program’s high dropout rate, they conducted detailed life interviews of almost 300 individuals • Researchers discovered that sexual abuse was common among dropouts, & that abuse always predated obesity

  7. Adverse Childhood Experiences (ACE) Study • As a follow-up, Kaiser Permanente & CDC conducted ACE study • Study involved 19,000 mostly middle class, middle aged adults • Results show childhood abuse & household dysfunction led to chronic diseases decades later • Traditionally viewed as public health problems, behaviors may also be coping mechanisms

  8. Adverse Childhood Experiences • Trauma in Child’s • Household • Substance Abuse • Parental divorce • Mentally ill or suicidal household member • Violence to mother • Imprisoned household member Child Abuse or Neglect • Physical abuse • Sexual abuse • Abandonment

  9. Adverse Childhood Experiences • Health Risk Behaviors • Smoking • Obesity • Suicide • Alcoholism • Drug abuse • Sexually transmitted disease • Self-injury • Eating disorders Effects of Trauma • Difficulty controlling anger • Hallucinations • Depression • Panic reactions • Anxiety

  10. Adverse Childhood Experiences Long-Term Consequences • Social Problems • Homeless • Prostitution • Delinquency, violence and criminal behavior • Re-victimizations: rape; domestic violence • Un-Employment • Inter-generational transmission of abuse Disease and Disability • Heart disease • Cancer • Chronic lung disease • Emphysema • HIV/AIDS • Mood disorders • Anxiety disorders

  11. Adverse Childhood Experiences & Smoking

  12. Adverse Childhood Experiences & Attempted Suicide

  13. Adverse Childhood Experiences & Intravenous Drug Use

  14. Adverse Childhood Experiences Death Early Death Disease, Disability, and Social Problems Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Adverse Childhood Experiences Birth

  15. II. The “Education” Context What you don’t know can kill you.

  16. Texas High School Graduation Rate2002 - 2003 Source: Texas Educations Agency AEIS Report

  17. Education: The Greatest Predictor of Longevity • The overall death rate for people 25- 64 with less than 12 years education is more than twice that for people with 13 or more years of education. • Less than 12 years of education: 615.6 deaths per 100,000 • 13 or more years of education: 207.9 deaths per 100,000 • The lower the education level, the greater the likelihood that individuals will engage in unhealthy behaviors. CDC National Center for Health Statistics, Vital Statistics Vol. 53, #5, Deaths, 2002

  18. Leisure Time Physical Activity (Texas), By Education Level, 2002-2003 Percent

  19. Prevalence of Obesity by Education Source: American Journal of Preventative Medicine, 2004;27 (3S)

  20. Health Literacy Most medical information on internet written at12th grade level Average American reads at 8th-9th grade level Average Medicaid recipient reads at 5th grade level

  21. III. The “Economic” Context Are we getting our money’s worth?

  22. Growth in National Health Expenditures 1980–2011 from $1,000 to $9,000 $6000 (2004) Per Capita Costs Levit et al. Health Affairs 2002;21:172–181. *Projection from Heffler et al. Health Affairs 2002;21:207–218.

  23. The Rising Spiral of Health-Care Costs • Healthcare premiums are growing more than 3 times faster than workers’ wages and 2.5 times faster than the inflation rate • Percentage of employers providing health benefits • 2000 69% • 2005 60% • Healthcare cost increases (national): • 2005 9.2% • 2004 11.2% • 2003 13.9% 2005 Kaiser Foundation Survey

  24. The Rising Spiral of Health-Care Costs • State of Texas employee health care costs up 53% since 2000 • Health care now consumes 30% of total state budgets* • Medicaid alone accounts for 20%* *National Governor's Association Center for Best Practices

  25. The Price is Not Right The U.S. Ranks: Health Care Spending 1st Life Expectancy 28th U.S. $1.79 Trillion Source: The World Health Report 2003, Total Population at Birth.

  26. IV. The “Conceptual” Context Are we going to redefine health care to include medical care and public health?

  27. Causes of Death in United States – 2002 Actual Causes of Death2 Leading Causes of Death1 Heart Disease Tobacco Poor diet/lack of exercise3 Cancer Alcohol Stroke Chronic lower respiratory disease Infectious agents 112,000 Unintentional Injuries Pollutants/toxins Diabetes Firearms Sexualbehavior Pneumonia/influenza Alzheimer’s disease Motor vehicles Illicit drug use Kidney Disease Percentage (of all deaths) Percentage (of all deaths) Sources: 1 National Vital Statistics Reports, Vol. 53, No. 15, February 28, 2005. 2 Adapted from McGinnis Foege, updated by Mokdad et. al., 2000. 3 JAMA, April 20, 2005—Vol 293, No. 15, pg 1861.

  28. Increased Life Expectancy Increased years due to public health measures: 25 Increased years due to medical care advances: 5 Source: Centers for Disease Control and Prevention (CDC).

  29. Demand Older Heavier More Sedentary Un & Underinsured Health Illiterate Supply Increasing Access Improving Quality of Care Improving Technology Improving Meds Improving Workforce The Healthcare Equation is Out of Balance Demand Reduction Is Imperative

  30. Supply Increasing Access Improving Quality of Care Improving Technology Improving Meds Improving Workforce The Healthcare Equation is Out of Balance Health Promotion Demand Reduction Is Imperative

  31. V. The “Obesity” Challenge Is it really that serious?

  32. Obesity Trends Among U.S. Adults 1991 1996 2004 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% BRFSS, 1991, 1996, 2004

  33. 2005 Texas is 6th Most Obese Stateeach state more than 25% obese • Mississippi • Alabama • West Virginia • Louisiana • Tennessee • Texas, Kentucky, Michigan “How Obesity Policies are Failing in American” Trust for America’s Health August 2005,

  34. Preventing Childhood Obesity- Health in the Balance “Despite steady progress over most of the past century toward ensuring the health of our country’s children, we begin the 21st Century with a startling setback—an epidemic of childhood obesity.” - Institute of Medicine

  35. Prevalence of At Risk and Overweight in Texas Children, 2001 * At risk of overweight is >85th but <95th Percentile for BMI by Age/Sex **Overweight is > 95th Percentile for BMI by Age/Sex

  36. Causes of Overweight/Obesity • Too many calories in; too few calories burned • 1977-1993 Average daily food intake increases by almost 200 calories • 1960 McDonalds serving of Fries = 200 calories • 2000 McDonalds serving of Fries = 610 calories New England Journal of Medicine, 5/22/03 review of “Fat Land” by Greg Critser

  37. Overweight and Obesity-Pediatric Conditions Affecting Children • Type 2 Diabetes Mellitus • High Blood Pressure • High Cholesterol • Gallbladder Disease • Sleep apnea • Behavioral Health Problems Source: Overweight and Obesity Health Consequences. National Center for Chronic Disease Prevention and Health Promotion.

  38. The Cost of Overweight and Obesity in Texas, 2010-2040

  39. Three Disturbing Trends Obesity and Diabetes: CDC NHANES; Expenditures: CMS, Health 2004

  40. Texans with Diagnosed Diabetes1994 - 2004

  41. Who Will Develop Diabetes? 1/3 of American children 2/5 of blacks & Hispanics 1/2 of Hispanic females CDC.gov/nccdphp/aag/aag_ddt.htm

  42. Diabetes: Almost $1 of every $5 spent on health care in the U.S. is for a person with diabetes Source: *Diabetes Care, Volume 26, Number 3, March 2003, p926

  43. Cost of Diabetes in Texas ~1.5 millionTexans with diabetes $13,240* Annual medical costs with diabetes $ 5,640* Age-adjusted average annual per person costs without diabetes $ 7,600 Added cost due to diabetes per person $11.4 billion Added cost to treat 1.5m Texans with diabetes : *Diabetes Care, Volume 26, Number 3, March 2003

  44. Projected Diagnosed Diabetes in the U.S. Projected number of people with diagnosed diabetes (millions) Population growth assumption Projected High Middle Low Reported U.S. Census Bureau, National Health Interview Survey (NHIS), CDC, NCHS. Boyle et al. Diabetes Care, Vol. 24, No.11, November 2001.

  45. Diabetes Prevention Program:Lifestyle Modification vs. Metformin Compared with the placebo intervention, the lifestyle and metformin interventions both increased the quality-adjusted life years (QALY) by: • $31,300 per QALY for metformin • $1,100 per QALY for lifestyle interventions March 2005 Annals of Internal Medicine Vol. 142 #5

  46. VI. Getting off the critical list Some good efforts are already underway

  47. AAP: Overweight & Obesity • Prevalence in pediatric populations has reached epidemic proportions • Prevention is critical • Early recognition of excessive weight gain should be routine • Families should be educated to recognize the influence they have on children’s health habits • Dietary habits should be fostered that encourage moderation • Regular physical activity should be consciously promoted

  48. Pediatric Obesity: A Clinical Toolkit for Healthcare Providers Diagnosis Overview Treatment Overview Practitioners’ Tools Patient Handouts

  49. Policy: Strategic Plan for the Prevention of Obesity in Texas • 4 Goals for Obesity Prevention • Awareness • Mobilizing families, schools, and communities • Promote policies and environmental changes • Monitor obesity rates and related behaviors http://www.tdh.state.tx.us/phn/obesity%2Dplan.pdf

  50. State Initiatives re: Obesity • Dept. of Ag Nutrition Policy/vending machines • Legislative mandates to authorize physical activity through 8th grade • Mandatory requirement to have a School Health Advisory Council (SHAC) in every school district • Re-establishment of statewide SHAC

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